Journal of Anesthesiology & Clinical Science ISSN 2049-9752 Special Section | General Anesthesia | Research Open Access Use of hypnosis as a substitute premedication and adjunct to anesthesia

Harsha Shanthanna1* and Vidya Jeurkar2 *Correspondence: [email protected] 1Department of Anesthesiology and Pain Medicine, Michael DeGroote School of Medicine, McMaster University, Canada. 2Department of Anesthesiology, Dr VM Medical College, Maharashtra, India.

Abstract Background: Surgery is associated with significant anxiety and stress in a majority of patients. Most medications used to achieve anxiolysis and sedation are limited by their side effects. ‘Non-pharmacological hypnosis’ is defined as a subjective state, during which alterations of perception and memory can be elicited by suggestions. Methods: In this prospective, observational study, hypnosis was used in fifteen patients for a range of surgeries; as a complementary technique to achieve sedation, establishment of intravenous (IV) access, and to decrease the anesthetic dose and postoperative nausea, vomiting. Results: Hypnosis successfully reduced the anxiety from a range of 45 to 90 (median of 60) to a range of 1 to 20 (median of 10). When calculated and analysed as means, the mean decrease was 56 (95% CI: 51.81, 60.04) with a p<0.001. Twelve out of fifteen patients had their intravenous access established under hypno-analgesia with no memory of that event. Thirteen patients had successful prevention of nausea, vomiting without antiemetics. Hypnosis also decreased the dose of induction agent in all patients having general anesthesia. Conclusion: Increasing knowledge and sophistication in anaesthesiology has given a wide spectrum of anesthetic agents and equipments to choose. However, achievement of sedation, anxiolysis and IV access are still areas of challenge which need more human interaction rather than administration of a miracle agent. We aim to demonstrate that hypnosis is well suited for such a purpose and should be utilised, at least in suitable patients. Keywords: Hypnosis, sedation, anxiolysis, intravenous access, hypnoanesthesia, hypnoanalgesia

Introduction subject comes out of the trance stage-for example: prevention Hypnosis is defined as state of focussed attention with heig- of nausea and vomiting. We studied the use of hypnosis as a htened receptivity for acceptable suggestions [1]. Although complementary technique to achieve non pharmacological hypnotism is known to have been practiced by many people, sedation, establishment of intravenous (IV) access, decrease it was James Braid who popularised its use in anesthesia. With in other anesthetic agents and improved analgesia with lesser the advent and rapid popularity of nitrous oxide, ether and side effects. chloroform, and also thanks to the discredit from the use of hypnosis by stage hypnotists and charlatans, the use of hypnosis Methodology in anesthesia dwindled [2]. The regained interest and use of This observational, prospective case series (study) was done at hypnosis in anesthesia practice can be largely attributed to the a well recognised post graduate medical college and hospital recognition by British Medical Association (1995) and American in India. Prior approval from the institutional ethics board was Medical Association (1958). Later to that the use of hypnosis obtained. All techniques were done under the supervision of has still been sporadic and limited to a few places. It is mostly our professor (VJ), coauthor of this article. Dr VJ is an anesth- practiced as a complementary technique, rather than a sole esiologist who is also trained in hypnoanesthesia and has several anaesthetic technique. However, there are places where it is publications to her credit on the same topic. All patients involved used as a sole anesthetic, even for major surgery. The procedure were explained about the technique and a written consent begins with induction, during which time the patient is taken obtained, either from the patient or their parent (in the case of into a trance stage. The depth of trance obtained could be light, children). We studied the use of hypnosis as a complementary medium or deep; and it depends upon both the subject and the tool to produce anxiolysis, sedation and analgesia for various hypnotist. For medical use, including sedation and anxiolysis, surgical procedures. Primary objectives were; 1) to decrease even light stage is beneficial [3]. Suggestions are delivered to perioperative anxiety and as a tool for sedation, 2) to establish the patient (subject) depending upon the goals of the session. analgesia and amnesia for IV access. Secondary objectives were; Post-hypnotic suggestions are those which are targeted at 1) to decrease anesthetic requirements, 2) to prevent nausea physiological and psychological modifications, even after the and vomiting by hypnosis, along with producing a smoother

© 2013 Shanthanna et al; licensee Herbert Publications Ltd. This is an Open Access article distributed under the terms of Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0). This permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Shanthanna et al. Journal of Anesthesiology and Clinical Science 2013, http://www.hoajonline.com/journals/pdf/2049-9752-2-25.pdf doi: 10.7243/2049-9752-2-25

sedative medications with or without full anesthesia. Exclusion criteria included patient or parent refusal, cognitive impairment or psychiatric disease which is moderate to severe, patient’s inability to comprehend the spoken language. Patients were screened for hypnotic suggestibility by tests such as eyeball set or hand levitation test, done at least a day prior to surgery and appropriate response noted [3]. The level of anxiety was also noted in VAS scale (1-100). Out of 18 cases screened for susceptibility by suggestions and observation, 13 patients were chosen. Two other cases were done on an emergency basis. All selected patients were informed about the visual analogue scale for anxiety (0-100). On the day of surgery, the anxiety scale was again assessed and noted. Hypnosis was induced mostly by verbalization (patient spoken to in the Figure 1. Hand Levitation technique. local language-Marathi or Hindi) method, by suggestions and commands aimed at “full body” relaxation; and when a light trance was achieved-noted by regular and relaxed respiratory movements and eye movements, verbalization was done specifically to achieve analgesia of the extremity (glove anesthesia), where an IV access was planned. The suggestions given to achieve analgesia of hands commonly included getting the hand slowly into a bucket full of ice, making it numb and insensate. The suggestions were reinforced by ideomotor and ideosensory responses. Other techniques to deepen the trance included hand levitation technique (Figure 1). In 12 out of 15 cases, IV access was tried under trance. The emergency cases had their IV access established prior to our intervention. In all 12 patients, sufficient analgesia for IV access was demonstrated by observing for response to pin prick (see Figure 2,3). After establishing IV access, patient was assessed for anxiety score, depth of trance and sedation Figure 2. Demonstration of hypnoanalgesia before IV by observation and patient response. Suggestions were insertion. administered with respect to the following; 1) safe, smoother and easier recovery, 2) effective pain relief, 3) effective prevention of nausea, vomiting and, 4) early discharge and return to activities. After that, sedation or anesthesia was induced appropriate to the surgical procedure. Two minor procedures were done only under hypnosis; and in 2 other high risk patients, minor surgical procedures were performed with only minimal doses of sedatives, apart from hypnosis. The actual procedures and anesthesia used is depicted in the (Table 1). During anesthesia, the dose of induction agents or sedatives administered was noted. Postoperatively, patients were questioned regarding the anxiety levels before going under anesthesia, any memory of intra-operative events, and adequacy of pain relief. Patient was further followed up till discharge for postoperative nausea and vomiting. Figure 3. Demonstration of hypnoanalgesia and IV insertion under hypnosis. Results The age of patients varied from 6 years to 68 years. Patient with ASA 1 to 3 were mostly included except a child of 6 years recovery due to posthypnotic suggestions. A total of 15 cases who had severe empyema, and a lady with severe anemia. In were studied and followed. Inclusion criteria included any all cases, satisfactory level of trance was achieved. Levels of surgical procedure necessitating IV access, use of analgesic and trance achieved are noted in (Table 2). Hypnosis significantly

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Table 1. List of Surgical Cases in Which Hypnosis Was Utilised. Induction/Sedative Nausea Age Sex ASA Procedures Anesthesia agent Vomiting 8 M 2 Tonsillectomy GA Thiopentone 2mg/kg No Thyroidectomy for Controlled Graves 1 episode 44 M 3 GA Thiopentone 2.5mg/kg Disease of vomiting only 26 F 1 Ganglion Excision Nil No HYPNOSIS Midazolam Dilation Currettage for 65 F 4 Minimal Sedation 1mg+Pentazocine No postmenopausal bleeding 6mg Interscalene brachial 60 M 3 Rt Humerus Plating Nil No plexus block

30 F 1 Fibroadenoma Excision GA Thiopentone 1.5mg/kg No

68 M 3 Inguinal Herniorrhaphy RA Inguinal Field Block Nil No

35 M 2 Laparascopic appendicectomy GA Thiopentone 2mg/kg No 42 F 1 Laparascopic Cholecystectomy GA Thiopentone 2.5mg/kg No Nausea+, 6 F 4 E ICD insertion for Severe Empyema Minimal Sedation Midazolam 0.5mg/kg no vomiting 14 M 1 Ilizarov’s Implant removal only HYPNOSIS Nil No 18 F 2 Closed Reduction and K wiring GA Thiopentone 2mg/kg No 16 M 2 E Debridement Ankle block Nil No 10 M 1 Suturing of lacerated wound GA Thiopentone 2mg/kg No 48 F 3 Mastectomy for Ca Breast GA Thiopentone 2.5mg/kg No

Table 2. Level of Hypnotic Trance Achieved. 56 with a SD of 11.33 (95% CI: 51.81, 60.04). The difference was statistically significant as observed by the P value< Level of Trance n=15 0.001 (paired Student t test). In 12 patients, hypnoanalgesia Light 8 to IV access was determined by response to pin prick (demonstrated in Figure 2 and 3), along with observation for Medium 4 change in heart rate, and eliciting memory for the event. Ten Deep 3 patients demonstrated complete analgesia with no change in heart rate; however, 2 patients demonstrated an increase in heart rate of less than 20 % from base line with memory of that event despite no response to pin prick. Three of the 15 patients had IV access pre-established for other reasons and could not be tested. In 2 patients in whom we noted deeper level of trance, procedures were done without any further use of sedatives or analgesics (Table 3). The patients were tested for response to pinch from surgical clip in the area and patients were continuously monitored with ASA (American Society of Anesthesiology) recommended monitoring standards and for any necessity of analgesic or anesthetic administration. In 2 other minor surgical procedures, only minimal sedation was used without any anesthetic agents. Both were in high risk patients who underwent the procedures without any complications Figure 4. Comparison of Anxiety; prior and after hypnosis. (Table 4). In all the above 4 patients, complete amnesia to intraoperative events apart from satisfactory sedation and decreased the level of anxiety in all patients, which is depicted analgesia was achieved. General anesthesia (GA) was used in (Figure 4). The level of anxiety prior to hypnosis was in the in 8 cases; 5 of them had endotracheal intubation. Hypnosis range of 45 to 90 with a median of 60 (VAS 0-100). Posthypnosis decreased the dose of IV induction agent (thiopentone the range of anxiety was 1 to 20 with a median of 10. When sodium) in all cases. The mean dose of induction agent calculated and analysed as means, the mean decrease was used was 2.12 mg/kg, demonstrating marked decrease in its

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Table 3. List of Cases Performed Only Under Hypnosis. in various surgeries [6] and invasive medical procedures [7]. Two other recent studies have shown the usefulness Cases Under Only Hypnosis Systemic Condition of hypnosis in decreasing preoperative anxiety. Saadat et Ganglion Excision of flexor tendon Right hand ASA 2 (hypertension) al., studied the use of hypnosis specifically for reduction Ilizarov’s implant removal ASA 1 of anxiety in ambulatory procedures and showed that ASA: American Society of Anesthesiology hypnosis was much more effective than attention-control, or the control group [6]. Calipel et al., compared the use of hypnosis with midazolam in children [8] and, they observed Table 4. List of Cases Performed Under Hypnosis and Minimal statistically significant decrease (p<0.05) in anxiety at mask Sedation. placement. One of the other primary objectives of our study Cases Systemic Disease/Condition Medications Used was to achieve a depth enough to create hypnoanalgesia, ICD ASA 4 Midazolam 0.5 mg + sufficient to introduce a 20G IV canula. Out of 12 patients, insertion (severe chest infection and empyema) Pentazocine 3 mg 10 patients felt no pain and did not remember the event. ASA 4 (IHD with post menopausal bleeding Midazolam 1 mg + The other two did not feel the pain but remembered the D and C with Hb 5.4 gm%) Pentazocine 9 mg event. Achieving IV access can often be very challenging, ASA: American Soceity of Anesthesiology especially in children. A significant proportion of children ICD: Intercostal Drain undergoing peripheral venipuncture suffer from moderate D and C: Dilation and Currettage to severe pain and elevated levels of pre-procedural and procedural distress. In fact many children report that this use when compared to the average dose normally used (4-6 could be on par with the surgical pain [9]. Disappointingly mg/kg). In all cases, successful induction was confirmed with sometimes, prior attempt at decrease in anxiety may be eyelash reflex, vocal response and response during intubation. nullified by the increasing anxiety and stress caused by The dose of muscle relaxant used to intubate was as per attempts at IV access. As demonstrated, our attempt at recommended doses. Since the study was mainly aimed at insertion happened after achieving sufficient depth to studying sedation and reduction of anxiety through hypnosis, produce relaxation and analgesia which was then tested by the reduction in doses of other intraoperative agents has not a hypodermic needle, after which the canula was inserted. been recorded. All patients showed complete amnesia and no No previous studies have tested the utility of hypnosis in recall of intraoperative events when assessed postoperatively. this regard. We feel hypnosis is particularly useful in this 13 out of 15 cases showed successful prevention of nausea, regard with extremely anxious and pediatric patients. vomiting by hypnosis while the 2 remaining patients had 1 Hypnoanalgesia, usually limited to a particular region of episode of severe nausea treated by antiemetic. the body, can be effected by suitable hypnotic commands and suggestions. Complete analgesia, sufficient for the Discussion entire surgical procedure is difficult and quite unpredictable. Our study demonstrates that non-pharmacological hypnosis However, hypnosis has been used as the sole anesthetic is a very effective tool to decrease the anxiety associated [10,11]. Even in experienced hands, considering only less than with surgical procedures. In our study, all patients showed a 10% of the general population can be hypnotised this way, decrease in their anxiety varying from 50% to complete relief. [3,4,10] it may not be meaningful to attempt a surgery under VAS scale has been previously shown to be a useful and valid only hypnosis except in unusual circumstances. Hypnosis has method for measuring preoperative anxiety, and correlated been effectively used along with sedation and local anesthesia well with (STAI) Speilberger State - Trait Anxiety Inventory [4]. for various regional procedures [12-14]. Although we did The reduction in anxiety was clinically and statistically very not plan to perform any procedure under only hypnosis, a significant. Clinically meaningful reduction of anxiety does total of 4 procedures were done without necessitating the not necessitate deeper level of trance [1,3]. Eight out of 15 use of any general anesthetic. Two procedures were done patients were observed to have only lighter level of trance. with only local anesthesia infiltration facilitated by hypnosis Surgical period is associated with significant distress, anxiety (Table 3). Two other procedures, in high risk patients, were and stress in at least 70% of patients [5]. Anxiety apart from done with the use of minimal sedation (Table 4). The demands causing visible distress to the patient puts him at risk of other of conscious sedation often include a high risk patient who adverse events [4]. It is more relevant in a high risk surgical cannot tolerate a GA [6,10]. Hypnosis helps by anxiolysis, patient where there is a decrease of systemic reserve which decreasing the requirements of other medications and even may necessitate decrease in anesthetic doses. Most common avoiding GA in suitable patients. More significantly hypnosis factors causing anxiety include; fear of unknown, fear of feeling achieves a state of mind which prevents sudden agitation ill, fear of waking up during surgery, fear of surgical pain. In and movement, which could be potentially dangerous in paediatric and young patients, fear of unknown dominates. ophthalmic and other surgeries [15]. Three procedures were Hypnosis has been successfully used to decrease anxiety done with the use of regional analgesia supplemented by

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hypnosedation. None of them required any additional IV 7. Lang EV, Benotsch EG, Fick LJ, Lutgendorf S, Berbaum ML, Berbaum sedatives or anesthetic agents. All the 8 patients of general KS, Logan H and Spiegel D: Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. Lancet 2000, anesthesia had smooth induction. The average (mean) dose of 355:1486-90. | Article | PubMed thiopentone was 2.12 mg/kg (1.5-2.5 mg/kg), demonstrating 8. Calipel S, Lucas-Polomeni MM, Wodey E and Ecoffey C:Premedication a decrease of >50% when compared to the normal range of in children: hypnosis versus midazolam. Paediatr Anaesth 2005, 4-6 mg/kg. Montgomery et al., demonstrated decrease use of 15:275-81. | Article | PubMed propofol in the hypnosis group; a mean difference of 32.63 9. Zempsky WT: Optimizing the management of peripheral venous access pain in children: evidence, impact, and implementation. 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Lewenstein LN, Iwamoto K and Schwartz H: Hypnosis in high risk tool for reduction of preoperative anxiety and sedation. The ophthalmic surgery. Ophthalmic Surg 1981, 12:39-41. | PubMed phenomenon of hypnoanalgesia can be utilised for IV access 16. Montgomery GH, Bovbjerg DH, Schnur JB, David D, Goldfarb A, Weltz and other minor medical procedures, which significantly CR, Schechter C, Graff-Zivin J, Tatrow K, Price DD and Silverstein JH: A reduces the overall distress and improves patient recovery. randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients. J Natl Cancer Inst 2007, 99:1304-12. | Article | PubMed Competing interests 17. Islam S and Jain PN: Post-operative nausea and vomiting (ponv): a The authors declare that they have no competing interests. review article. Indian J. Anaesth 2004, 48:253-258. | Pdf Authors’ contributions 18. 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